Entry Form

The road to recovery can be rocky, The Upper Room can offer you solace and help along the way.

Name *

First

Last

Email *

Phone *

I Struggle With... *

Substance Abuse

Alcoholism

Gambling Addiction

Binge / Purge Eating

Other

Check all that apply.

If Other, Please Explain To The Best Of Your Ability

Do You Have A Record of Criminal Sexual Or Violent Behavior? *

Yes

No

Are You Currently Clean/Sober? *

Yes

No

Have You Been Clean/Sober For At Least 30 Days? *

Yes

No

As The Upper Room is a second stage safe space for continued recovery, our residents need to have been clean/sober for at least 30 days and this time must be verifiable.

Can You Pass A Drug and Alcohol Screening? *

Yes

No

In order to provide a safe space for our residents to continue their recovery and personal growth we must ensure a drug and alcohol free atmosphere. Therefore one or more drug and alcohol screenings will be required for entry and continued stay at the Upper Room.

Do You Have The Ability To Get Along With Others *

Yes

No

Recovery is difficult, as can sharing a living space with others. In order to ensure a safe and calm environment for our residents, we need to know you can act responsibly and cordially with other residents and staff.

Are You Willing To Come With An Open Mind? *

Yes

I Want To Try

No

Our ideals, values, and beliefs are a cornerstone of our program. As such to truly benefit from your time at the Upper Room, you must be at least open to considering the options and different types of help we want to give you.

Do You Have Any Special Needs Or Considerations That We'd Need To Know About?

Required medications, disabilities, behavioral idiosyncrasies, or any other condition/requirement you feel is pertinent to staying at the Upper Room.

Notice Of Authenticity *

Agree

Disagree

I hereby swear that my answers to this questionnaire are honest and answered to the best of my ability. I acknowledge and understand that if any of my answers are found to be untrue that my application will be forfeit and if I was accepted into the program will result in my immediate expulsion from the Upper Room. I also agree to drug and alcohol screenings as deemed necessary by the Upper Room staff. Lastly, I release the Upper Room to run background & criminal record checks if needed.

Message

For me, I really needed time away from my old environment. I needed a place where people are in recovery and are serious about their recovery, a place where I could fit in and give my newly-found recovery a solid foundation.

anonymous

I’m finally getting better. I'm moving forward.

anonymous

Life is so much better. I had no idea the sweet life I could have.

anonymous

My alcoholism was so out of control and so was my life. I had a loss of trust with people who cared about me. It’s devastating. How do you regain that trust?

anonymous

I came here because of word of mouth about Upper Room. I’ve known about God most of my life, but I did not KNOW God.

anonymous

I've learned a lot about myself through this process. My character has changed. It's not easy, but with help, I know I can do it. It is God's will, not mine.

anonymous

The disease is arrested, not destroyed. Each day you have to decide whether you’re going to live or die – because it will kill you.

anonymous

When you’re in the midst of addiction, you’re also in the midst of loneliness and isolation. It’s hard to shake off. Your defense mechanisms are like a coat that you put on.